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Objectives: Repetitive transcranial magnetic stimulation (rTMS) is a potential new antidepressant method and alternative to electroconvulsive therapy (ECT). The efficacy of right prefrontal low-frequency rTMS was shown in a previous placebo-controlled, randomized study but has never been compared with ECT. The aim of this study was to compare the antidepressant efficacy and adverse effects of right prefrontal low-frequency rTMS with that of ECT.

Methods: Sixty inpatients with major depression were randomized to 15 days of 1-Hz right prefrontal rTMS or 9 unilateral ECTs. Depressive symptoms and adverse effects were recorded using the Hamilton Scale for Depression and the Udvalg for Kliniske Undersøgelser side effect scale, supplied by neuropsychological assessment of cognitive functions.

Results: Repetitive transcranial magnetic stimulation was significantly less effective than ECT. The intention-to-treat analysis revealed a 26% (confidence interval, 3%-51%) higher rate of partial remission (P = 0.035) by the end of week 3. There was no difference found between the 2 methods on the Udvalg for Kliniske Undersøgelser rating scale. However, psychological examination revealed ECT to have more adverse effects on cognitive functions, whereas the rTMS group improved particularly with respect to visual memory.

Conclusions: Repetitive transcranial magnetic stimulation was significantly less effective than ECT, but ECT had more adverse effects on cognitive function. The outcome does not point to right frontal low-frequency rTMS using the present stimulus design as a first-line substitute for ECT, but rather as a treatment option for patients with depression who are intolerant to other types of treatment or not accepting ECT.

From the *Aarhus University Hospital, Risskov and †Department of Biostatistics, Institute of Public Health, University of Aarhus, Arhus, Denmark.

The study was supported by the Danish Council for Medical Research, the pool to support research in psychiatry, Einar Geert-Jorgensen and wife Ellen Geert-Jorgensen Research Foundation, a Butcher Worzner and wife Inger Worzner grant, the Aarhus University Foundation for Research in Mental Diseases, and the Foundation of Psychiatric Research.